A nurse in the emergency room is assessing a patient who was brought in following a seizure. The nurse suspects the patient may have bacterial meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next?

Assess the cranial nerves.

Decrease environmental stimuli.

Close the room.

Administer an antipyretic.

Answer and Explanation

The Correct Answer is B

Choice A reason: Assessing the cranial nerves is important, but it is not the immediate next step after implementing droplet precautions for suspected bacterial meningitis.

Choice B reason: Decreasing environmental stimuli can help reduce the risk of seizures and is a supportive measure for a patient with suspected bacterial meningitis.

Choice C reason: Closing the room is part of implementing droplet precautions but is not an action that needs to be initiated by the nurse as it should already be in place.

Choice D reason: Administering an antipyretic may be necessary if the patient has a fever, but it is not the immediate next action after droplet precautions.

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Correct Answer is C

Explanation

Choice A: Sleepy, but arousing when the name is called
Feeling sleepy after receiving morphine is a common side effect. However, the fact that the client can be aroused when their name is called suggests that this is not necessarily an adverse effect.
The nurse should continue monitoring the client but may not consider this as a significant adverse reaction.

Choice B: Pain level of 6 on a scale from 0 to 10
Pain relief is one of the intended effects of morphine. Therefore, experiencing pain reduction is not an adverse effect.
The nurse would likely view this as a positive response to the medication.

Choice C: Respiratory rate of 8/min
A respiratory rate of 8 breaths per minute is significantly low and indicates respiratory depression, which is a serious adverse effect of morphine.
The nurse should be concerned about this finding and take appropriate action.

Choice D: SaO2 94%
An oxygen saturation (SaO2) level of 94% is within the normal range (usually 95% or higher). It is unlikely to be directly related to morphine administration.
While this value is not concerning, the nurse should continue monitoring the client's oxygen saturation.

A. Wash your hair with a mild protein shampoo. B. Apply powder liberally to sensitive skin areas. C. Use a sun blocking agent with a sun protection factor of at least 15. D. Avoid using moisturizing lotions on your skin. E. None F. None

Correct Answer is C

Explanation

Choice A reason: This is incorrect. While gentle hair care is important, it is not as critical as sun protection for SLE patients.

Choice B reason: This is incorrect. Powder can be drying, and SLE patients often need to keep their skin moisturized.

Choice C reason: This is correct. SLE patients are often photosensitive and need to protect their skin from UV rays.

Choice D reason: This is incorrect. SLE patients should keep their skin well moisturized to prevent dryness.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client 15 minutes after administering 2 mg of morphine sulfate via IV push. The nurse should identify which of the following findings as an adverse effect of the medication?

Correct Answer is C

Explanation

A nurse is performing discharge teaching for a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

A nurse is planning care for a client who is to receive packed RBCs. The nurse should plan for the total infusion time to not exceed which of the following?

A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)

A nurse is assessing a client who reports ear pain for the past three days that has suddenly resolved. The client has a new onset of otorrhea (drainage from the ear). The nurse should recognize the client has manifestations of which of the following conditions?

A nurse is caring for a client who has peripheral arterial disease (PAD). Which of the following symptoms should the nurse expect to find in the client?

A nurse is assessing a patient's immune function by reviewing the laboratory value of the cellular response of the T cells. The nurse should recognize that which of the following conditions is affected by the?

A nurse is reviewing the laboratory test results from a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect?

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